A PRISON officer watched an inmate in distress and gasping for breath but was unable to go to his assistance even though he had a key to the cell, an inquest heard.
The inquest jury in Wisbech was told prison rules prevented officers entering cells alone and there was a strict code of putting security before safety.
Inmate Dennis Smalley (59) died in his cell at Whitemoor prison, March, on May 26 last year, after suffering an acute asthma attack coupled with heart problems, concluded Home Office pathologist Dr Nat Cary.
Mr Smalley, who had been at the prison since 1994, was sentenced in 1993 to serve 20 years imprisonment for two counts of murder.
Prison officer Darren Parker told coroner William Morris there were regular checks on the high risk category A prisoners.
At 22.16am he looked through the inspection window into Smalley's cell. The inmate was sitting on his bed, using his nebuliser, and gave Mr Parker the thumbs-up.
One minute later he was alerted by an alarm in Smalley's cell and returned to find him lying on the floor and struggling for breath.
Mr Parker called his senior officer Desmond Chapman and prison nurse Bob Prince, who made their way to the cell, along with another officer and a dog handler. The cell was entered at 2.28am – 11 minutes after the emergency began.
Mr Parker said he had a key for the cell which was kept in a sealed pouch and had to be signed for at the start of each shift.
He was in a position to enter the cell, but staff were under instructions not to do so alone.
Asked what was the purpose of carrying the key he replied "to preserve life".
But he said this would be only in extreme situations and that because Smalley was still breathing he "deemed it not necessary to enter".
Desmond Chapman, in charge of the prison on the night of Smalley's death, told the jury officers were briefed every shift and reminded no cells should be opened without him being present.
Many years ago the rule was to put safety first and security second, but following the Whitemoor escape in 1994 the policy was reversed.
Mr Chapman said that in the past he had been into cells to help people "supposedly hanging" only to be attacked by the fake suicide inmate.
He said: "I will not put my staff in danger."
Asthma expert Dr John Shneerson told the inquest on Thursday it was unlikely the outcome would have been any different if Smalley had been attended to more quickly.
Nurse Bob Price said that when he arrived in the cell he could not find a pulse but gave Smalley artificial respiration until Dr Debanjan Nandy arrived and pronounced Smalley dead at about 3am.
The jury concluded Mr Smalley had died of natural causes and that staff at the prison and the medical team present had made every effort to revive him.